This story makes a one-side case for ‘minimally invasive" rotator cuff surgery.
This is an important topic: is “minimally invasive” arthroscopic surgery a safe and effective treatment for painful rotator cuff tears among men and women age 70 or over?
Unfortunately, the brief article never provided an adequate answer. It relied heavily on a press release. It didn’t offer a critical look at the study the press release promoted. It didn’t mention that the authors of the new study received funding from manufacturers of surgical equipment. It didn’t discuss costs.
Most importantly, the story didn’t provide a balanced view of the overall body of evidence on the treatment of rotator cuff tears.
Like the study and press release, the article suggested that arthroscopic rotator cuff surgery may be a safe and effective treatment for older patients—providing significant pain relief, improvements in strength and range of motion, and return to normal function.
These assertions could all be true. But the new study—a retrospective case series of 40 patients—has design issues that make it incapable of proving those points.
The same holds true for the larger body of evidence on the surgical treatment of rotator cuff tears. A recent review of 137 studies sponsored by the Agency for Healthcare Quality and Research (AHRQ) suggested that there are many potential therapies, surgical and nonsurgical, for painful rotator tears.
However, all the evidence has flaws and no single treatment stands out above others, in terms of proven safety and effectiveness. (See Seida JC et al., Annals of Internal Medicine, July, 2010; see http://www.annals.org/content/early/2010/07/01/0003-4819-153-4-201008170-00263.full)
The LA Times article should have explained that key point. Patients and their physicians can’t make informed choices about treatments for rotator cuff tears without understanding the nature of the evidence—including its flaws.
Rotator cuff tears are common throughout adulthood, and are increasingly prevalent with advancing years.
Rotator cuff tears do not always cause symptoms. In studies of pain-free volunteers, up to a quarter of adults have evidence of a rotator cuff tear on imaging.
But when rotator cuff tears do cause symptoms, the pain can be debilitating— frustrating normal activities, compromising sleep, and sapping peace of mind. Their impact can be particularly onerous on older individuals grappling with other age- and health-related problems.
Scientific studies have not yet precisely defined the indications for rotator cuff surgery. And its appropriateness is a particular issue among older individuals, where bone, circulation and other health issues may hamper healing and recovery. Given these uncertainties, it is vital that scientific studies employ rigorous methods to accurately assess the outcomes of different treatments—and for different age groups.
When those studies report their results, it is imperative that journalists interpret the evidence critically—and not merely rubber-stamp the results of press releases and marketing documents.
The article didn’t mention cost or reimbursement issues. Yet this is an important topic. “Minimally invasive” doesn’t mean cheap. Arthroscopic rotator cuff surgery ranges in price from $7000 to more than $20,000, according to various estimates.
The article did not adequately quantify the benefit of the arthroscopic surgery for rotator cuff tears. It explained that 96% of study subjects reported “significant” pain reduction but didn’t explain how this translated in real-life terms. The article noted that patients reported improved function (in both range of motion and strength). but did not quantify “improved.”
The article didn’t explain that the lack of a control group made the improvements difficult to interpret. This leads to the question: "Did the patients improve more with surgery than they would have with a non-surgical treatment program?" That question will only be answered with controlled trials.
The article did not address potential complications and adverse effects associated with arthroscopic rotator cuff surgery among older patients.
The LA Times story did not discuss the methodological quality of the new study or the larger body of evidence on rotator cuff tears.
Readers deserved to hear that the new study—because of its retrospective nature, highly selected patient population, and lack of control group—was incapable of proving the safety and efficacy of arthroscopic rotator cuff surgery for any age group. At best, this is a preliminary study that sets the stage for rigorous randomized controlled trials.
The article did not engage in disease mongering. However, it did not make it clear that rotator cuff tears don’t always cause symptoms—and don’t always require treatment.
The article did not identify the source of the story—or whether it came from a press release. It did not include commentary from an independent expert who was not associated with the study.
In addition, the article did not provide information on potential conflicts of interest among the study authors. Yet the study clearly states that one or more of the authors received funding and/or consulting fees from manufacturers of surgical devices employed in shoulder surgery—which could have biased the design, conduct, and reporting of the study.
The article mentioned two alternative treatments that were also cited in the press release: surgical debridement and medication. It did not mention that there are numerous treatments and treatment protocols for rotator cuff tears—including surgical, nonsurgical, and combined approaches.
It is curious that this article did not mention exercise therapy as a potential treatment, since exercise plays some role in nearly every treatment protocol for rotator cuff tears.
It is important that patients with painful rotator cuff tears understand that they have many treatment options—and can choose one that aligns with their preferences, values and tolerance for risk.
The article didn’t identify the type of arthroscopic surgery under study—or its availability.
The article didn’t provide any details about the type of arthroscopic rotator cuff surgery under study. So it wasn’t clear if this is a novel approach or not.
The article appeared to rely heavily on a press release. Most of the information in the article, including a quote from the lead author, can be found in a press release from Rush-Presbyterian Hospital that was published at Newswise.com, Eurekalert.org, and other medical news sites (see release at Newswise.com: http://www.newswise.com/articles/surgery-to-repair-torn-shoulder-muscles-in-the-elderly-can-reduce-pain-and-improve-function?ret=/articles/list&category=medicine&page=1&search[status]=3&search[sort]=date desc&search[section]=10&search[has_multimedia]=).